Provider Demographics
NPI:1972884427
Name:KOONTZ, MIMI (LCSW)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3212
Mailing Address - Country:US
Mailing Address - Phone:541-743-2611
Mailing Address - Fax:541-868-0340
Practice Address - Street 1:550 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3212
Practice Address - Country:US
Practice Address - Phone:541-743-2611
Practice Address - Fax:541-868-0340
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL47111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical